Legal highs: regulation won’t work – the only answer lies in prevention

Author

Chair in Clinical Pharmacology and Therapeutics, University of Hertfordshire

Disclosure statement

Fabrizio is a member of the UK advisory council on the misuse of drugs. He has also received EC funding in relation to researching the effects of novel psychoactive substances. These views are his own and in no way represent either the council or the EC.

In one respect, the world’s drug problem is not getting much worse. The UN believes that the use of drugs such as cocaine and heroin has stabilised, for example. In fact, the ground in the drugs battle has just shifted. The focus is now increasingly on legal highs.

People might be aware that altered versions of ecstasy or cannabis are available nowadays, but the true range of what we in the trade call novel psychoactive drugs is far more varied. There are derivatives of everything from ketamine to cocaine, from opiates to psychotropics. Their use is rising, and so is the number of fatalities. Some people fear that the figures are only going in one direction.

Enforcers vs chemists

Why has this happened? In recent years there was a worldwide decrease in the purity of drugs like amphetamine and cocaine and the MDMA content of ecstasy. This decrease helped fuel demand for alternatives (though admittedly there are signs that this purity decrease is now reversing). The internet has also made possible the sort of sharing of information that makes it much easier to sell these substances nowadays. And as has been well documented, banning these drugs is difficult because the manufacturers can constantly bring out new varieties with slight alterations to the chemistry.

It has turned into a battle between the drug enforcers and the drug chemists, who are typically based in the Far East, for example in China and Hong Kong. There are many databases online with information on the molecular structures of existing drugs. This makes it easier for these people to modify them to create a new product.

The market is very strong in the UK. You might think it is because the information online is often written in English. This would explain why Ireland has a big problem too, but then again the US does not. And other problem countries include Latvia, Hungary, Estonia and Russia.

The big worries

Certain categories particularly worry us. One is the ecstasy derivatives known as phenethylamines. One of the well-known ones in the UK is PMA, which has been nicknamed “Dr Death” because of the number of fatalities. Another is known as “blue mystique”. These have been made illegal in a number of European countries, but many more keep appearing. A related group is known as NBOMe, which are very powerful and therefore also a great concern.

Then there are cannabimimetics, which are sometimes known as the “spice drugs”. There are a few hundred known variations, many of which are very powerful, sometimes thousands of times more than cannabis. They were behind the “spiceophrenia” epidemic in Russia, but are prevalent closer to home too. Last week a new HM Prisons report mentioned them among a number of legal-high concerns in British prisons. To make matters worse, they are very easy to modify and have the big selling point that they can’t always be traced in urine.

Sometimes legal highs are marketed as a solution to a problem that an illegal drug might cause. For example ketamine (“special K”) is known to damage the intestine and bladder, so a new drug reached the market called methoxetamine, or “special M,” which claimed to be bladder-friendly. But in fact it is still toxic for the bladder and also the kidney and central nervous system. And after it was made illegal, a number of other derivatives appeared such as diphenidine. The health risks associated with this class makes the new versions particularly scary.

The unwinnable battle?

We often don’t know how these drugs affect people. Researchers like myself are working on this, but the number of new substances is increasing too quickly for us to keep up. By the time we publish papers focusing on more popular versions, the market has changed. When something goes wrong, doctors don’t know how to treat the effects – in many cases they can’t even ascertain the exact drug.

We have reached the point where I am now more worried about legal highs than illegal drugs. Whenever I see a heroin client in my clinic, I know exactly what to do. That is often not the case with legal highs. And as a psychiatrist I know that they potentially have far more psychiatric consequences than heroin. Whenever you tamper with very sensitive mechanisms in your brain, it’s difficult to know what will happen.

One argument is that we should keep these drugs legal since we are facing an unwinnable battle. But the big drawback with this is that it makes adolescents and other susceptible people think that the drug must be safe. New Zealand tried this approach by permitting drugs to remain in circulation if the producers could demonstrate they were low risk, but this year the government U-turned after there were a number of adverse incidents.
Now its approach is similar to the UK with its expanding prohibition schedule.

The problem with the New Zealand low-risk policy is that establishing the safety of a drug is a very slow process if you are going to do it properly. Proving through clinical trials that a drug works, is safe and is not toxic takes upwards of 10 years. Anything less would be cutting corners. If a manufacturer were to go through that process and prove that a drug was low risk, that might be a different discussion, but it’s not going to help with today’s problem.

Similarly there has been some debate about permitting the supply of legal highs but keeping it tightly restricted – perhaps allowing one distributor per town, for example. But this both ignores the reality of the internet and offers no answer to the safety problem.

Another possibility is to legalise the illegal drugs that we know much more about, so that people are encouraged to take them instead. But even if this was politically possible, it doesn’t sound like the right course of action either. I see disasters from drug-taking on a daily basis. And it wouldn’t necessarily stop people from taking legal highs anyway.

The answer to what we actually should do is complex. The answer probably lies in prevention: we need dedicated resources and funding, we need new ideas to try and convince youngsters that these drugs are not safe just because they are legal. This requires a big change in how we see these substances. These are not just some marginal concern. This is the new drug battle for the decades ahead.

Health Canada is proposing a new system to fast-track urgent drugs for children, the elderly and those with serious or life-threatening conditions. This would rely on decisions made by regulators in other jurisdictions.
(Shutterstock)